Low Testosterone In Women

Overview

Testosterone is a sex hormone in women and men that plays a variety of important roles in the body. In women, testosterone is important for sexual function, vaginal health, cognition, and bone health.¹ Low testosterone is often seen in premenopausal and postmenopausal women and is associated with a loss of muscle tone, fatigue, low sexual desire (hypogonadism), menstrual irregularities/an inability to conceive, and increased stress/anxiety.

Current research surrounding testosterone in women is focused on excessive production - which causes increased facial hair, loss of scalp hair, infertility, and acne. However, decreased testosterone levels have largely been ignored in the premenopausal population despite evidence that low testosterone affects the libido of both premenopausal and postmenopausal individuals.²

There are some testosterone replacement strategies for women to reduce the symptoms caused by low testosterone. This treatment is preferably administered topically because of good tolerability and lack of serious side effects. Whilst testosterone replacement is not licensed in the UK, off-licence preparations are recommended in the National Institute for Health and Care Excellence (NICE) guidelines (NICE). However- because they are off-licence, it is very important to consult a local healthcare professional in addition to the manufacturer’s instructions. 

Causes of low testosterone in women

Low testosterone in women can come about spontaneously or iatrogenically (caused by medical intervention/treatment). The most common causes are age (spontaneous), oophorectomy (surgical removal of the ovaries), and oral oestrogens (iatrogenic).³

Spontaneous causes of low testosterone in women include:⁴

• Increase in age
• Panhypopituitarism - reduction in all hormone production by the pituitary gland
• Hypothalamic amenorrhea - lack of menstrual cycle due to hormonal reduction, usually caused by severe stress, malnutrition, or intensive exercise
• Primary ovarian insufficiency - premature (before age 40) loss of ovarian function
• Hyperprolactinemia - increased levels of the prolactin hormone, responsible for breast milk production. A spontaneous increase in this hormone indicates pituitary dysfunction.
• Adrenal insufficiency - the adrenal (kidney) glands make insufficient hormones, including cortisol, testosterone, and aldosterone. This is rare, termed Addison’s Disease. 
• Other medical conditions (e.g., chronic liver disease and HIV infection)

Iatrogenic causes of low testosterone in women include:⁵

• Oophorectomy - removal of one or both ovaries surgically
• Chemotherapy
• Radiotherapy to the pelvis
• Drug-induced hyperprolactinemia - some antidepressants and antihypertensive medication can induce low testosterone production. 
• Systemic hormonal contraception - some oral contraceptives, such as the combined pill, reduce levels of androgens (sex hormones, including testosterone) 
• Oral non-contraceptive therapy - contraceptives may also be used for menorrhagia (prolonged/severe periods) and endometriosis. 

Signs and symptoms of low testosterone in women

Symptoms of low testosterone can mimic other medical conditions:^6,7,8

• Low sexual desire (decreased sexual thoughts, fantasies, actions)
• Fatigue
• Lack of energy
• Lack of focus
• Headaches
• Less pleasurable sex (reduced genital arousal and orgasmic response)
• Muscle weakness (especially athletes)
• Decreased vaginal lubrication
• Lack of well-being

Some evidence suggests that low testosterone levels increase the likelihood of depression, but this remains controversial.⁹ There is evidence that testosterone levels are different between premenopausal and postmenopausal individuals both with and without depression. However, a meta-analysis has suggested that low testosterone levels are a manifestation of depression rather than a cause.¹⁰

Management and treatment for low testosterone in women

Taking medication to increase testosterone levels in women has been shown to be effective and reduce symptoms. The reduction in symptoms may be due to not only increased testosterone but also due to higher oestrogen levels in the bloodstream; testosterone is an oestrogen precursor, and this process of steroid hormone conversion is prevalent in those assigned females at birth (AFAB).

In the UK, there are no testosterone medications licensed for women. However, it is still possible to get treatment for low testosterone in women by using medicinal treatments that are not licensed in the UK. Because these treatments are off-licence, it is very important to follow the instructions given by a doctor or other medical professional, as the manufacturer’s instructions are not specific to low testosterone in women.11 It is also not possible to take medication for low testosterone if you are pregnant, breastfeeding, have had hormone-sensitive breast cancer, or are a competitive athlete.¹⁰

Treatment effectiveness may take up to 4 weeks to manifest and show signs of improvement. If there is no improvement in the symptoms after 3 months, then the doctor may suggest increasing the dosage or discuss alternative steps to take. Any follow-up appointments will be with your GP.¹¹

Testosterone replacement is preferred via non-oral routes. Gels are the most common prescription and are the safest method for testosterone replacement. These include Testim gel (1%), Testogel (1%), or Tostran (2%).¹¹

Instructions for Testosterone Gel Replacement:

• Apply to clean skin on the lower abdomen/upper thighs
• Immediately wash hands after application
• Let gel dry 
• Avoid skin contact with other people until the gel is dry
• Avoid washing the skin for 2-3 hours after application

Tibolone is a different sort of medication that may be administered to women with low testosterone, but there is evidence that this is less effective than the medications already listed. Tibolone is not testosterone but a steroid that increases testosterone levels.¹¹

The benefits of testosterone replacement in women include:¹²

• Improved musculoskeletal health (bone density, muscle strength)
• Increased cognitive function up to pre-menopausal levels
• Increased sexual desire/libido and arousal
• Increased sexual activity frequency and sexual satisfaction
• Reduced sexual concern and distress
• Improved self-image and energy

Testosterone replacement can also have effects that AFAB patients may find adverse. These include:¹³

• Increased body hair at the site of application
• Hirsutism - increased body hair at all sites, most commonly the face and neck
• Alopecia - loss of hair on top of the head
• Greasy skin
• Acne
• Deeper voice
• Larger clitoris

These changes can bring about cosmetic concerns for patients. However, there is no evidence that taking testosterone replacement brings any risks or health detriment14, and it is preferred to continue with low testosterone levels. Side-effects are usually dose-related. A study over two years showed that women receiving testosterone therapy had no serious side effects and demonstrated that low-dose testosterone replacement is effective in postmenopausal women.¹⁵ 

Before starting testosterone replacement, a doctor may take a blood test. Another blood test is then taken after three months of treatment to compare testosterone levels in the bloodstream and to ensure that testosterone levels are in the healthy normal range. 

Diagnosis

A diagnosis can usually be made based on symptoms and medical history. In some cases, a blood test will be taken to confirm low testosterone levels.

In some cases, low testosterone in women may be misdiagnosed by doctors and overlooked by patients. The symptoms have been commonly attributed to anxiety, depression, premenstrual syndrome, lack of sleep, or lifestyle changes.¹⁶

FAQs

How can I prevent low testosterone in women?

Low testosterone in women can come about spontaneously or iatrogenically (medically induced by treatment of a different condition). Low testosterone levels in women cannot be prevented if they come about spontaneously. However, a discussion with a doctor before treatment of other medical conditions would be useful regarding the likelihood of other treatments affecting testosterone levels and what to expect if it did result in low testosterone levels.

How common is low testosterone in women?

43% of women aged between 18 to 19 in the United States have sexual dysfunction. In the US, it is estimated that between 10 to 15 million women have low testosterone.¹⁶

It is estimated that 8 to 19% of women have hypoactive sexual desire disorder, which may be related to low testosterone.¹⁷

Who is at risk of low testosterone in women?

It is possible for women to develop low testosterone levels at any time between their teen years to old age

There is evidence that mothers of young children and monogamy are associated with low testosterone levels.^18,19 

What can I expect if I have low testosterone?

Women with low testosterone experience a multitude of symptoms, most commonly a loss of sexual desire (low libido). Other symptoms include reduced sexual pleasure, reduced vaginal lubrication, and fatigue, among others. Whether low testosterone is a cause of low mood or a consequence of it remains unknown.

If diagnosed with low testosterone, medication can be prescribed by a doctor to raise your testosterone levels back to the normal range. This should reduce the symptoms. However, these medications may take 4 weeks to demonstrate their effects. Regardless, there is evidence to suggest that medical intervention for women with low testosterone is effective at reducing the symptoms of low testosterone.

When should I see a doctor?

You should see a doctor if you are experiencing (some of) the symptoms described associated with low testosterone in women:

• Low sexual desire (decreased sexual thoughts, fantasies, actions)
• Fatigue
• Lack of energy
• Lack of focus
• Headaches
• Less pleasurable sex (reduced genital arousal and orgasmic response)
• Muscle weakness (especially athletes)
• Decreased vaginal lubrication
• Lack of well-being

These are particularly prevalent in AFAB people of perimenopausal or menopausal age, as well as those with existing hormonal disorders. A doctor will be able to further assess you and prescribe you medication, if necessary, to reduce these symptoms.

Summary

Low testosterone in women can be seen in both premenopausal and postmenopausal women, affecting women from their early teens to old age. Doctors can diagnose this through patient examination and history, although a blood test may also be taken to confirm testosterone levels in the blood. Commonly, low testosterone in women is caused iatrogenically by oophorectomy or oral estrogens or spontaneously related to increasing age. There are effective treatments for testosterone replacement in women with low testosterone - in which the most commonly prescribed are gels. Side effects from the gels are rare and dose-dependent. Alternative treatments and dosing will be discussed with a doctor after three months if no improvement of symptoms is found.